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Burnett County Office of Zoning Administrator <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br />Permit for the work described and located as shown herein. The undersigned agrees that all <br />work shall be done in accordance with the requirements of the County Zoning Ordinance, <br />Sanitation Code, and with all other applicable County Ordinances and the laws and regu- <br />latio//nn,s,,,,,of the State of Wisconsin. <br />666.0 .is...... M ... a ...................................... <br />Owner or Agent (please print) Contractor or Surveyor <br />Address Address <br />( y -a .............................. . <br />Phone Phone <br />Plumber . ............................. Well Driller........................... . <br />Address...... ........................ Address.............................. <br />Phone............................... .Phone.............................. <br />DESCRIPTION <br />4. Building Details <br />7. Sanitary Facilities: <br />1. Work <br />Type of9onstruction <br />W.Q. L N t.<<'1 <br />No. Bathrooms <br />No. Bedrooms <br />New Building ...... <br />.. . <br />.^� .. . <br />Size ft. x . 3.'ON ft. <br />Septic Tank Size Gals. <br />Addition ...... <br />Height ).6: Stories .. <br />...... <br />Sanitary <br />Area .... kti.l�. ,tg.jo <br />7a.Absorption Field Site: <br />Filling ...... <br />Soil Type .................. <br />Moving ...... <br />5. Permits Required <br />Slope .................... <br />Grading ...... <br />Subdivision , , • ... <br />Perc. Rate ................. <br />Mobile Home ...... <br />Sanitary <br />Dry Well ...... <br />Privy ...... <br />Building <br />Seepage Trench ...... <br />Well ...... <br />Well • , • , • , <br />Privy ...... <br />Subdivision ...... <br />Other (Specify) ...... <br />Seepage Bed ...... <br />Conditional ...... <br />I <br />_Ln B <br />d H <br />C <br />CD <br />CD <br />CL <br />� v <br />r+ m <br />c <br />CD <br />o_ <br />i` <br />Z <br />0 <br />—O <br />Z Z <br />0 0 <br />-n T <br />M m <br />o <br />g <br />2. Classification Land Use ...... <br />Zoning Dist. . . <br />6. Use (describe exactly, 1 fam. <br />3. Cot Size) home, motel, etc.) FOR COMMERCIAL USE <br />ft. x ... ►Ot)-M (,atti '✓1" Pla s Submitted <br />.......... sq. ft o Plans Approved <br />—�---- —+~ _ -Off f' f-y—�Lqi--------- <br />"T {O Fig A. Location of proposed structures and <br />existing structures, well, sewage sys- <br />tems, roads, etc., should be sketched <br />�aJ in Fig. A. Include road setback, side <br />and back yard dimension and location <br />and setback from all bodies of water. <br />,t <br />�., i If property is located at a highway in- <br />tersection, show the intersecting high- <br />ways and the setbacks required along <br />them and at the intersection. <br />4 <br />PERMIT FEES <br />4. Vj Subdivision..... $25.00 + $2.00 per lot. <br />v4 <br />� <br />� <br />INS orb f Land Use ................................. $10.00 <br />Fe Building ................................... 10.00 <br />a <br />N Sanitary .................................. 20.00 <br />�. well ........................................ 10.00 <br />\ Septic Tank ............................ 10.00 <br />it-, toll Privy ....................................... 5.00 <br />Fli or)L <br />9A�� ......... <br />... ..... ....... <br />Si n re of Owner or ent ��^ Qate <br />Inspection Date ................................................ Inspector ........................... <br />Zor(ing Administrator <br />0 o <br />o' �+ <br />o <br />0 <br />0 <br />Cn <br />C M <br />e <br />N <br />1C <br />0 <br />CD <br />Remarks........................................................................................................................................................ <br />................................................................................................................................................................................................ <br />NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br />ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />